Cancer Progress for Whom?

I read Carlos Amábile-Cuevas’s article “Zeroing in on Cancer” (September–October) with interest. Not long ago, I was diagnosed with squamous-cell carcinoma of the rectum that seemed relatively simple to treat with decades-old chemotherapy drugs and radiation. But since I learned of my illness, both my mother and my wife have been diagnosed with stage III and stage II breast cancer, respectively. I am learning as much as I can about their options. Both appear to be HER2 positive so both are using trastuzumab in combination with powerful, also decades-old drugs such as cytoxan, adriamycin and Cisplatin. So much of this seems to date to World War II chemical warfare.

I agree that the search for profits can inhibit potential new customized therapies. However, another problem needs attention. As treatment complexity increases, it’s harder for patients to make informed decisions. Should my wife be taking Cisplatin like my mother? Should my mother be taking taxol like my wife? While my mother is clearly HER2 positive, my wife is borderline, so there is no certainty it will help. And why weren’t cetuximab, erlotinib or gefitinib, which Amábile-Cuevas describes, offered? Combine these options with advances in radiation therapy (treatments that cost a bucketful of money) and the complexity grows. Let’s not even discuss options such as CellSearch’s Circulating Tumor Cell Test technologies that can find a tumor cell in the bloodstream at 1 part per billion but not always its source.

Rather than more customized therapies addressing single cancer types, therapies that address more universal cancer mechanisms (such as metastasis) are needed. They could shrink the number of treatment options to scales that patients can better manage.

James V. GruberWashington, NJ

Dr. Amábile-Cuevas responds:

Mr. Gruber raises several important issues. One is patients’ desire to make informed decisions. Although many physicians do not like this “second-guessing,” it is in everyone’s best interests. The complexities of new treatments make it harder, even for the oncologist, to choose treatments. Since we are not abandoning older treatment options for exclusively newer drugs, complex regimes will continue. Special efforts must be made to communicate the rationale for these treatments.

Oncology is constantly evolving. Some drugs used now against some cancers will be useful against other cancers, but clinical trials are needed to demonstrate that. These trials can take many years. Some, for economic reasons, will never be done. Medical insurance will not pay for off-label drug uses. Although waiting for efficacy and safety data is crucial when dealing with non- life-threatening conditions, this might not be the case for cancer—something that regulatory agencies must consider. We are moving toward a midpoint between universal cancer therapies and individual, affordable, custom-made treatment. But this will not happen soon. And this is not going to get simpler.